Neurology of ciguatera

Detection of Extremely Low Level Ciguatoxins through Monitoring of Lithium Adduct Ions by Liquid Chromatography-Triple Quadrupole Tandem Mass Spectrometry

Ciguatera poisoning (CP) is the most common type of marine biotoxin food poisoning worldwide, and it is caused by ciguatoxins (CTXs), thermostable polyether toxins produced by dinoflagellate Gambierdiscus and Fukuyoa spp. It is typically caused by the consumption of large fish high on the food chain that have accumulated CTXs in their flesh. CTXs in trace amounts are found in natural samples, and they mainly induce neurotoxic effects in consumers at concentrations as low as 0.2 µg/kg. The U.S. Food and Drug Administration has established CTX maximum permitted levels of 0.01 µg/kg for CTX1B and 0.1 µg/kg for C-CTX1 based on toxicological data. More than 20 variants of the CTX1B and CTX3C series have been identified, and the simultaneous detection of trace amounts of CTX analogs has recently been required. Previously published works using LC-MS/MS achieved the safety levels by monitoring the sodium adduct ions of CTXs ([M+Na]+ > [M+Na]+). In this study, we optimized a highly sensitive method for the detection of CTXs using the sodium or lithium adducts, [M+Na]+ or [M+Li]+, by adding alkali metals such as Na+ or Li+ to the mobile phase. This work demonstrates that CTXs can be successfully detected at the low concentrations recommended by the FDA with good chromatographic separation using LC-MS/MS. It also reports on the method's new analytical conditions and accuracy using [M+Li]+.

An Unusual Presentation of Severe Ciguatera Poisoning: Case Report

BACKGROUND Ciguatera poisoning is presently estimated to afflict approximately 16 000 people in the United States each year. Ciguatera toxicity is due to the ingestion of warm-water reef fish that are known to consume dinoflagellates that contain ciguatoxins (CTXs). Historically, the diagnosis of ciguatera poisoning is confirmed in the emergency department when this ingestion is followed by manifestations of neurologic and gastrointestinal organ symptoms. Some individuals also manifest cardiac symptoms. These symptoms can vary within each organ system in type and duration. CASE REPORT In this report, 2 patients (husband and wife) are presented that consumed the same barracuda, resulting in severe ciguatera poisoning diagnosed in the emergency department. One had the complete triad of symptoms of gastrointestinal (GI), neurologic, and cardiac involvement. The other patient lacked neurological symptoms but did experience severe gastrointestinal and cardiac symptoms. It was assumed by the inpatient team, the consulted infectious disease specialist, and, initially, the in-house toxicologist that the lack of neurologic symptoms excluded the diagnosis of ciguatera. CONCLUSIONS If these patients had presented separately, only the former would have been considered to have ciguatera poisoning. These 2 cases demonstrate the misunderstanding among healthcare practitioners of the literature on the diagnostic criteria. Therefore, this article aims to analyze ciguatera diagnosis in the emergency department, which will ultimately guide prognostics and management, particularly for severe cardiac symptoms.

Ciguatera Fish Poisoning in the Caribbean Sea and Atlantic Ocean: Reconciling the Multiplicity of Ciguatoxins and Analytical Chemistry Approach for Public Health Safety

Ciguatera is a major circumtropical poisoning caused by the consumption of marine fish and invertebrates contaminated with ciguatoxins (CTXs): neurotoxins produced by endemic and benthic dinoflagellates which are biotransformed in the fish food-web. We provide a history of ciguatera research conducted over the past 70 years on ciguatoxins from the Pacific Ocean (P-CTXs) and Caribbean Sea (C-CTXs) and describe their main chemical, biochemical, and toxicological properties. Currently, there is no official method for the extraction and quantification of ciguatoxins, regardless their origin, mainly due to limited CTX-certified reference materials. In this review, the extraction and purification procedures of C-CTXs are investigated, considering specific objectives such as isolating reference materials, analysing fish toxin profiles, or ensuring food safety control. Certain in vitro assays may provide sufficient sensitivity to detect C-CTXs at sub-ppb levels in fish, but they do not allow for individual identification of CTXs. Recent advances in analysis using liquid chromatography coupled with low- or high-resolution mass spectrometry provide new opportunities to identify known C-CTXs, to gain structural insights into new analogues, and to quantify C-CTXs. Together, these methods reveal that ciguatera arises from a multiplicity of CTXs, although one major form (C-CTX-1) seems to dominate. However, questions arise regarding the abundance and instability of certain C-CTXs, which are further complicated by the wide array of CTX-producing dinoflagellates and fish vectors. Further research is needed to assess the toxic potential of the new C-CTX and their role in ciguatera fish poisoning. With the identification of C-CTXs in the coastal USA and Eastern Atlantic Ocean, the investigation of ciguatera fish poisoning is now a truly global effort.

Contribution of Mass Spectrometry to the Advances in Risk Characterization of Marine Biotoxins: Towards the Characterization of Metabolites Implied in Human Intoxications

A significant spread and prevalence of algal toxins and, in particular, marine biotoxins have been observed worldwide over the last decades. Marine biotoxins are natural contaminants produced during harmful algal blooms being accumulated in seafood, thus representing a threat to human health. Significant progress has been made in the last few years in the development of analytical methods able to evaluate and characterize the different toxic analogs involved in the contamination, Liquid Chromatography coupled to different detection modes, including Mass Spectrometry, the method of choice due to its potential for separation, identification, quantitation and even confirmation of the different above-mentioned analogs. Despite this, the risk characterization in humans is still limited, due to several reasons, including the lack of reference materials or even the limited access to biological samples from humans intoxicated during these toxic events and episodes, which hampered the advances in the evaluation of the metabolites responsible for the toxicity in humans. Mass Spectrometry has been proven to be a very powerful tool for confirmation, and in fact, it is playing an important role in the characterization of the new biotoxins analogs. The toxin metabolization in humans is still uncertain in most cases and needs further research in which the implementation of Mass Spectrometric methods is critical. This review is focused on compiling the most relevant information available regarding the metabolization of several marine biotoxins groups, which were identified using Mass Spectrometry after the in vitro exposition of these toxins to liver microsomes and hepatocytes. Information about the presence of metabolites in human samples, such as human urine after intoxication, which could also be used as potential biomarkers for diagnostic purposes, is also presented.

Clinical Characteristics of Ciguatera Poisoning in Martinique, French West Indies—A Case Series

Ciguatera poisoning (CP) is one of the most common causes worldwide of marine poisoning associated with fish consumption from tropical areas. Its incidence is underreported. CP cases seem to increase with grouped cases reported during summer. Exposure to ciguatoxins, toxins responsible for CP with sodium-channel agonistic, voltage-gated potassium channel blocking, cholinergic, and adrenergic activities, may result in a large spectrum of manifestations. We aimed to describe the clinical characteristics, management, and outcome of CP in Martinique, French West Indies. We conducted an observational retrospective single-center study during six years (October 2012 to September 2018) including all CP patients managed by the prehospital medical services, admitted to the university hospital emergency department, or declared to the regional health agency. A total of 149 CP patients (81 females/63 males; median age, 46 years (interquartile range, 34–61)) were included. Acute features consisted in general (91%; mainly, myalgia pruritus, and asthenia), gastrointestinal (90%; mainly diarrhea, abdominal pain, and nausea), neurological (72%; mainly, paresthesia, dysgeusia, and impairment of hot/cold feeling), and cardiovascular manifestations (22%; bradycardia, hypotension, and heart conduction disorders). Management was supportive. No patient died but symptoms persisted in 40% of the 77 patients with follow-up at day 15. CP was mainly attributed to the ingestion of trevallies (59%), snappers (13%), and king mackerels (8%) with collective contaminations (71%). Unusual fish (tuna, salmon, and spider conchs) were suspected in rare cases. Ingestion of trevallies was associated with significantly higher persistent symptoms (odds ratio, 3.00; 95% confidence interval, (1.20–8.00); p = 0.03). CP incidence was 0.67 cases per 10,000 patient-years in Martinique over the study period. To conclude, CP represents an increasing public health issue in Martinique, as is the case in other Caribbean islands. Patients present usual but possibly life-threatening features. Outcome is excellent despite frequently prolonged manifestations.

In vivo subchronic effects of ciguatoxin-related compounds, reevaluation of their toxicity

Ciguatoxins are marine compounds that share a ladder-shaped polyether structure produced by dinoflagellates of the genus Gambierdiscus and Fukuyoa, and include maitotoxins (MTX1 and MTX3), ciguatoxins (CTX3C) and analogues (gambierone), components of one of the most frequent human foodborne illness diseases known as ciguatera fish poisoning. This disease was previously found primarily in tropical and subtropical areas but nowadays, the dinoflagellates producers of ciguatoxins had spread to European coasts. One decade ago, the European Food Safety Authority has raised the need to complete the toxicological available data for the ciguatoxin group of compounds. Thus, in this work, the in vivo effects of ciguatoxin-related compounds have been investigated using internationally adopted guidelines for the testing of chemicals. Intraperitoneal acute toxicity was tested for maitotoxin 1 at doses between 200 and 3200 ng/kg and the acute oral toxicity of Pacific Ciguatoxin CTX3C at 330 and 1050 ng/kg and maitotoxin 1 at 800 ng/kg were also evaluated showing not effects on mice survival after a 96 h observation period. Therefore, for the following experiments the oral subchronic doses were between 172 and 1760 ng/kg for gambierone, 10 and 102 ng/kg for Pacific Ciguatoxin CTX3C, 550 and 1760 ng/kg for maitotoxin 3 and 800, 2560 and 5000 ng/kg for maitotoxin 1. The results presented here raise the need to reevaluate the in vivo activity of these agents. Although the intraperitoneal lethal dose of maitotoxin 1 is assumed to be 50 ng/kg, without chemical purity identifications and description of the bioassay procedures, in this work, an intraperitoneal lethal dose of 1107 ng/kg was obtained. Therefore, the data presented here highlight the need to use a common procedure and certified reference material to clearly establish the levels of these environmental contaminants in food.

Update on Toxic Neuropathies

Purpose of Review

Toxic neuropathies are an important preventable and treatable form of peripheral neuropathy. While many forms of toxic neuropathies have been recognized for decades, an updated review is provided to increase vigilant in this area of neurology. A literature review was conducted to gather recent information about toxic neuropathies, which included the causes, clinical findings, and treatment options in these conditions.

Recent Findings

Toxic neuropathies continue to cause significant morbidity throughout the world and the causative agents, particularly with regards to medications, do not appear to be diminishing. A wide variety of causes of toxic neuropathies exist, which include alcohol, industrial chemicals, biotoxins, and medications. Unfortunately, no breakthrough treatments have been developed and prevention and symptom management remain the standard of care.

Summary

A detailed medication, occupational and hobby exposure history is critical to identifying toxic neuropathies. Increased research is warranted to identify mechanisms of neurotoxic susceptibility and potential common pathomechanistic pathways for treatment across diverse toxic neuropathies.

Identification of New CTX Analogues in Fish from the Madeira and Selvagens Archipelagos by Neuro-2a CBA and LC-HRMS

Ciguatera Poisoning (CP) is caused by consumption of fish or invertebrates contaminated with ciguatoxins (CTXs). Presently CP is a public concern in some temperate regions, such as Macaronesia (North-Eastern Atlantic Ocean). Toxicity analysis was performed to characterize the fish species that can accumulate CTXs and improve understanding of the ciguatera risk in this area. For that, seventeen fish specimens comprising nine species were captured from coastal waters inMadeira and Selvagens Archipelagos. Toxicity was analysed by screening CTX-like toxicity with the neuroblastoma cell-based assay (neuro-2a CBA). Afterwards, the four most toxic samples were analysed with liquid chromatography-high resolution mass spectrometry (LC-HRMS). Thirteen fish specimens presented CTX-like toxicity in their liver, but only four of these in their muscle. The liver of one specimen of Muraena augusti presented the highest CTX-like toxicity (0.270 ± 0.121 µg of CTX1B equiv·kg−1). Moreover, CTX analogues were detected with LC-HRMS, for M. augusti and Gymnothorax unicolor. The presence of three CTX analogues was identified: C-CTX1, which had been previously described in the area; dihydro-CTX2, which is reported in the area for the first time; a putative new CTX m/z 1127.6023 ([M+NH4]+) named as putative C-CTX-1109, and gambieric acid A.

An Extensive Survey of Ciguatoxins on Grouper Variola louti from the Ryukyu Islands, Japan, Using Liquid Chromatography–Tandem Mass Spectrometry (LC-MS/MS)

Ingesting fish contaminated with ciguatoxins (CTXs) originating from epibenthic dinoflagellates causes ciguatera fish poisoning (CFP). CFP occurs mainly in the tropical and subtropical Indo–Pacific region and the Caribbean Sea. Furthermore, it occurs sporadically in Japan, especially in the Ryukyu Islands between Taiwan and Kyushu, Japan. Variola louti is the most frequently implicated fish with a suggested toxin profile, consisting of ciguatoxin-1B and two deoxy congeners. Therefore, using the liquid chromatography–tandem mass spectrometry (LC-MS/MS), we analyzed CTXs in the flesh of 154 individuals from various locations and detected CTXs in 99 specimens (64%). In 65 fish (43%), CTX levels exceeded the Food and Drug Administration (FDA) guidance level (0.01 µg/kg). Furthermore, in four specimens (3%), the guideline level in Japan (>0.18 µg/kg) was met. Additionally, although the highest total CTX level was 0.376 µg/kg, the consumption of 180 g of this specimen was assumed to cause CFP. Moreover, only CTX1B, 52-epi-54-deoxyCTX1B, and 54-deoxyCTX1B were detected, with the relative contribution of the three CTX1B analogs to the total toxin content (35 ± 7.7 (SD)%, 27 ± 8.1%, and 38 ± 5.6%, respectively) being similar to those reported in this region in a decade ago. Subsequently, the consistency of the toxin profile in V. louti was confirmed using many specimens from a wide area. As observed, total CTX levels were correlated with fish sizes, including standard length (r = 0.503, p = 3.08 × 10−11), body weight (r = 0.503, p = 3.01 × 10−11), and estimated age (r = 0.439, p = 3.81 × 10−7) of the specimens. Besides, although no correlation was observed between condition factor (CF) and total CTX levels, a significance difference was observed (p = 0.039) between the groups of skinnier and fattier fish, separated by the median CF (3.04). Results also showed that the CF of four specimens with the highest CTX level (>0.18 µg/kg) ranged between 2.49 and 2.87, and they were skinnier than the average (3.03) and median of all specimens.

Current Trends and New Challenges in Marine Phycotoxins

Marine phycotoxins are a multiplicity of bioactive compounds which are produced by microalgae and bioaccumulate in the marine food web. Phycotoxins affect the ecosystem, pose a threat to human health, and have important economic effects on aquaculture and tourism worldwide. However, human health and food safety have been the primary concerns when considering the impacts of phycotoxins. Phycotoxins toxicity information, often used to set regulatory limits for these toxins in shellfish, lacks traceability of toxicity values highlighting the need for predefined toxicological criteria. Toxicity data together with adequate detection methods for monitoring procedures are crucial to protect human health. However, despite technological advances, there are still methodological uncertainties and high demand for universal phycotoxin detectors. This review focuses on these topics, including uncertainties of climate change, providing an overview of the current information as well as future perspectives.

Determination of the toxicity equivalency factors for ciguatoxins using human sodium channels

Ciguatoxins (CTXs) which are produced by dinoflagellates of the genus Gambierdiscus and Fukuyoa and share a ladder-shaped polyether structure, are causative compounds of one of the most frequent foodborne illness disease known as ciguatera fish poisoning (CFP). CFP was initially found in tropical and subtropical areas but nowadays the dinoflagellates producers of ciguatoxins had spread to European coasts. Therefore, this raises the need of establishing toxicity equivalency factors for the different compounds that can contribute to ciguatera fish poisoning, since biological methods have been replaced by analytical techniques. Thus, in this work, the effects of six compounds causative of ciguatera, on their main target, the human voltage-gated sodium channels have been analyzed for the first time. The results presented here led to the conclusion that the order of potency was CTX1B, CTX3B, CTX4A, gambierol, gambierone and MTX3. Furthermore, the data indicate that the activation voltage of sodium channels is more sensitive to detect ciguatoxins than their effect on the peak sodium current amplitude.

Screening for Predictors of Chronic Ciguatera Poisoning: An Exploratory Analysis among Hospitalized Cases from French Polynesia

Ciguatera poisoning is a globally occurring seafood disease caused by the ingestion of marine products contaminated with dinoflagellate produced neurotoxins. Persistent forms of ciguatera, which prove to be highly debilitating, are poorly studied and represent a significant medical issue. The present study aims to better understand chronic ciguatera manifestations and identify potential predictive factors for their duration. Medical files of 49 patients were analyzed, and the post-hospitalization evolution of the disease assessed through a follow-up questionnaire. A rigorous logistic lasso regression model was applied to select significant predictors from a list of 37 patient characteristics potentially predictive of having chronic symptoms. Missing data were handled by complete case analysis, and a survival analysis was implemented. All models used standardized variables, and multiple comparisons in the survival analyses were handled by Bonferroni correction. Among all studied variables, five significant predictors of having symptoms lasting ≥3 months were identified: age, tobacco consumption, acute bradycardia, laboratory measures of urea, and neutrophils. This exploratory, hypothesis-generating study contributes to the development of ciguatera epidemiology by narrowing the list from 37 possible predictors to a list of five predictors that seem worth further investigation as candidate risk factors in more targeted studies of ciguatera symptom duration.

An Update on Ciguatoxins and CTX-like Toxicity in Fish from Different Trophic Levels of the Selvagens Islands (NE Atlantic, Madeira, Portugal)

The Selvagens Islands, which are a marine protected area located at the southernmost point of the Portuguese maritime zone, have been associated with fish harboring ciguatoxins (CTX) and linked to ciguatera fish poisonings. This study reports the results of a field sampling campaign carried out in September 2018 in these remote and rarely surveyed islands. Fifty-six fish specimens from different trophic levels were caught for CTX-like toxicity determination by cell-based assay (CBA) and toxin content analysis by liquid chromatography with tandem mass spectrometry (LC-MS/MS). Notably, high toxicity levels were found in fish with an intermediate position in the food web, such as zebra seabream (Diplodus cervinus) and barred hogfish (Bodianus scrofa), reaching levels up to 0.75 µg CTX1B equivalent kg⁻¹. The LC-MS/MS analysis confirmed that C-CTX1 was the main toxin, but discrepancies between CBA and LC-MS/MS in D. cervinus and top predator species, such as the yellowmouth barracuda (Sphyraena viridis) and amberjacks (Seriola spp.), suggest the presence of fish metabolic products, which need to be further elucidated. This study confirms that fish from coastal food webs of the Selvagens Islands represent a high risk of ciguatera, raising important issues for fisheries and environmental management of the Selvagens Islands.

Pacific-Ciguatoxin-2 and Brevetoxin-1 Induce the Sensitization of Sensory Receptors Mediating Pain and Pruritus in Sensory Neurons

Ciguatera fish poisoning (CFP) and neurotoxic shellfish poisoning syndromes are induced by the consumption of seafood contaminated by ciguatoxins and brevetoxins. Both toxins cause sensory symptoms such as paresthesia, cold dysesthesia and painful disorders. An intense pruritus, which may become chronic, occurs also in CFP. No curative treatment is available and the pathophysiology is not fully elucidated. Here we conducted single-cell calcium video-imaging experiments in sensory neurons from newborn rats to study in vitro the ability of Pacific-ciguatoxin-2 (P-CTX-2) and brevetoxin-1 (PbTx-1) to sensitize receptors and ion channels, (i.e., to increase the percentage of responding cells and/or the response amplitude to their pharmacological agonists). In addition, we studied the neurotrophin release in sensory neurons co-cultured with keratinocytes after exposure to P-CTX-2. Our results show that P-CTX-2 induced the sensitization of TRPA1, TRPV4, PAR2, MrgprC, MrgprA and TTX-r NaV channels in sensory neurons. P-CTX-2 increased the release of nerve growth factor and brain-derived neurotrophic factor in the co-culture supernatant, suggesting that those neurotrophins could contribute to the sensitization of the aforementioned receptors and channels. Our results suggest the potential role of sensitization of sensory receptors/ion channels in the induction or persistence of sensory disturbances in CFP syndrome.

Characteristic Distribution of Ciguatoxins in the Edible Parts of a Grouper, Variola louti

Ciguatera fish poisoning (CFP) is one of the most frequently encountered seafood poisoning syndromes; it is caused by the consumption of marine finfish contaminated with ciguatoxins (CTXs). The majority of CFP cases result from eating fish flesh, but a traditional belief exists among people that the head and viscera are more toxic and should be avoided. Unlike the viscera, scientific data to support the legendary high toxicity of the head is scarce. We prepared tissue samples from the fillet, head, and eyes taken from five yellow-edged lyretail (Variola louti) individuals sourced from Okinawa, Japan, and analyzed the CTXs by LC-MS/MS. Three CTXs, namely, CTX1B, 52-epi-54-deoxyCTX1B, and 54-deoxyCTX1B, were confirmed in similar proportions. The toxins were distributed nearly evenly in the flesh, prepared separately from the fillet and head. Within the same individual specimen, the flesh in the fillet and the flesh from the head, tested separately, had the same level and composition of toxins. We, therefore, conclude that flesh samples for LC-MS/MS analysis can be taken from any part of the body. However, the tissue surrounding the eyeball displayed CTX levels two to four times higher than those of the flesh. The present study is the first to provide scientific data demonstrating the high toxicity of the eyes.

Ciguatera poisonings: A global review of occurrences and trends

Ciguatera Poisoning (CP) is the most prevalent, phycotoxin related seafood poisoning across the globe, affecting between 10,000 and 50,000 people annually. This illness results from the consumption of seafood contaminated with lipid soluble toxins known as ciguatoxins (CTXs) that are produced by benthic dinoflagellates in the genera Gambierdiscus and Fukuyoa. The present work reviews the global occurrence of CP events and outbreaks, based on both scientific and gray literature. Ciguatera prevalence is significantly underestimated due to a lack of recognition of ciguatera symptoms, limited collection of epidemiological data on a global level, and reticence to report ciguatera in CP-endemic regions. Analysis of the time-series data available for a limited number of countries indicates the highest incidence rates are consistently reported from two historical CP-endemic areas i.e., the Pacific and Caribbean regions, a situation due in part to the strong reliance of local communities on marine resources. Ciguatera-related fatalities are rare (<0.1% of reported cases). The vast majority of outbreaks involve carnivorous fish including snappers, groupers, wrasses, and barracudas. Since 2000, an expansion of the geographical range of CP has been observed in several areas like Macaronesia and east and southeast Asia. In some of these locales, random surveys confirmed the presence of CTXs in locally sourced fish, consistent with the concurrent report of novel CP incidents (e.g., Canary Islands, Madeira, Selvagens Islands, New South Wales). One characteristic of outbreaks occurring in Asia is that they often present as large disease clusters due to group consumption of a single contaminated fish. Similar observations are reported from the Indian Ocean in the form of shark poisoning outbreaks which often lead to singular types of CP characterized by a high fatality rate. Other atypical forms of CP linked to the consumption of marine invertebrates also have been documented recently. Owing to the significant health, socioeconomic and socio-cultural impacts of ciguatera, there is an urgent need for increased, standardized, coordinated efforts in ciguatera education, monitoring and research programs. Several regional and international initiatives have emerged recently, that may help improve patients' care, data collection at a global scale, and risk monitoring and management capabilities in countries most vulnerable to CP's toxic threat.

A review of food poisoning caused by local food in Japan

Increasingly popular worldwide, Japanese cuisine includes several raw preparations such as sashimi and sushi; however, limited information on food poisoning from Japanese local food is available in English literature. Without appropriate knowledge, physicians may underdiagnose traveler's diarrhea among people returning from Japan. To provide accurate information to primary care physicians worldwide, we conducted a narrative review on food poisoning research published in Japanese and English over the past four years, considering the frequency and clinical importance of various presentations.

Evidence for the Range Expansion of Ciguatera in French Polynesia: A Revisit of the 2009 Mass-Poisoning Outbreak in Rapa Island (Australes Archipelago)

Ciguatera poisoning (CP) results from the consumption of seafood contaminated with ciguatoxins (CTXs). This disease is highly prevalent in French Polynesia with several well-identified hotspots. Rapa Island, the southernmost inhabited island in the country, was reportedly free of CP until 2007. This study describes the integrated approach used to investigate the etiology of a fatal mass-poisoning outbreak that occurred in Rapa in 2009. Symptoms reported in patients were evocative of ciguatera. Several Gambierdiscus field samples collected from benthic assemblages tested positive by the receptor binding assay (RBA). Additionally, the toxicity screening of ≈250 fish by RBA indicated ≈78% of fish could contain CTXs. The presence of CTXs in fish was confirmed by liquid chromatography tandem mass spectrometry (LC-MS/MS). The potential link between climate change and this range expansion of ciguatera to a subtropical locale of French Polynesia was also examined based on the analysis of temperature time-series data. Results are indicative of a global warming trend in Rapa area. A five-fold reduction in incidence rates was observed between 2009 and 2012, which was due in part to self-regulating behavior among individuals (avoidance of particular fish species and areas). Such observations underscore the prominent role played by community outreach in ciguatera risk management.

Neurological Disturbances of Ciguatera Poisoning: Clinical Features and Pathophysiological Basis

Ciguatera fish poisoning (CFP), the most prevalent seafood poisoning worldwide, is caused by the consumption of tropical and subtropical fish contaminated with potent neurotoxins called ciguatoxins (CTXs). Ciguatera is a complex clinical syndrome in which peripheral neurological signs predominate in the acute phase of the intoxication but also persist or reoccur long afterward. Their recognition is of particular importance in establishing the diagnosis, which is clinically-based and can be a challenge for physicians unfamiliar with CFP. To date, no specific treatment exists. Physiopathologically, the primary targets of CTXs are well identified, as are the secondary events that may contribute to CFP symptomatology. This review describes the clinical features, focusing on the sensory disturbances, and then reports on the neuronal targets and effects of CTXs, as well as the neurophysiological and histological studies that have contributed to existing knowledge of CFP neuropathophysiology at the molecular, neurocellular and nerve levels.

Peripheral Neuropathies Due to Vitamin and Mineral Deficiencies, Toxins, and Medications

PURPOSE OF REVIEW

Vitamin and mineral deficiencies, neurotoxins, and, particularly, prescription medications, are some of the most common causes of peripheral neuropathy. Recognition and prompt treatment of these neuropathies require a high index of suspicion and an accompanied detailed history. This article provides a comprehensive approach and list of items that must be considered in the setting of new-onset neuropathy.

RECENT FINDINGS

Although many of the neuropathies described in this article have decreased in prevalence in developed countries because of public health interventions and occupational/environmental regulations, new causes for this class of neuropathy continue to be uncovered.

SUMMARY

The peripheral nervous system is susceptible to a broad array of metabolic and toxic abnormalities, which most often lead to a length-dependent sensory-predominant axonal peripheral neuropathy. A careful history accompanied by recognition of multisystem clues can increase recognition of these neuropathies, which is important as many have specific treatments that may either improve the neuropathy or halt its progression.

Toxin-Induced Channelopathies, Neuromuscular Junction Disorders, and Myopathy

Channelopathies, neuromuscular junction disorders, and myopathies represent multiple mechanisms by which toxins can affect the peripheral nervous system. These toxins include ciguatoxin, tetrodotoxin, botulinum toxin, metabolic poisons, venomous snake bites, and several medications. These toxins are important to be aware of because they can lead to serious symptoms, disability, or even death, and many can be treated if recognized ear.

Acute Sensory and Autonomic Neuronopathy: A Devastating Disorder Affecting Sensory and Autonomic Ganglia

Acute-onset and severe sensory and autonomic deficits with no motor dysfunction, typically preceded by a febrile illness, with poor recovery, and often fatal outcome are the hallmark features of acute sensory and autonomic neuronopathy (ASANN). Pathologically and electrophysiologically, ASANN is characterized by an extensive ganglionopathy affecting sensory and autonomic ganglia with preservation of motor neurons. Consequently, patients, usually children or young adult, develop acute-onset profound widespread loss of all sensory modalities resulting in automutilations, as well as autonomic failure causing neurogenic orthostatic hypotension, neurogenic underactive bladder, and gastroparesis and constipation. The diagnosis is clinical with support of nerve conduction studies and autonomic testing, as well as spinal cord magnetic resonance imaging showing characteristic posterior cord hyperintensities. Although the presumed etiology is immune-mediated, further studies are required to clarify the physiopathology of the disease. We here performed a systematic review of the epidemiology, pathophysiology, diagnosis, and management of ASANN, with three representative cases that recently presented at our clinic. All three patients had the typical clinical manifestations of ASANN but in different combinations, illustrating the variable phenotype of the disorder. Immunosuppression is seldom effective. Management options are limited to supportive and symptomatic care with the goal of minimizing complications and preventing death.

PAR2, Keratinocytes, and Cathepsin S Mediate the Sensory Effects of Ciguatoxins Responsible for Ciguatera Poisoning

Ciguatera fish poisoning is caused by the consumption of fish contaminated with ciguatoxins (CTXs). The most distressing symptoms are cutaneous sensory disturbances, including cold dysesthesia and itch. CTXs are neurotoxins known to activate voltage-gated sodium channels, but no specific treatment exists. Peptidergic neurons have been critically involved in ciguatera fish poisoning sensory disturbances. Protease-activated receptor-2 (PAR2) is an itch- and pain-related G protein‒coupled receptor whose activation leads to a calcium-dependent neuropeptide release. In this study, we studied the role of voltage-gated sodium channels, PAR2, and the PAR2 agonist cathepsin S in the cytosolic calcium increase and subsequent release of the neuropeptide substance P elicited by Pacific CTX-2 (P-CTX-2) in rat sensory neurons and human epidermal keratinocytes. In sensory neurons, the P-CTX-2‒evoked calcium response was driven by voltage-gated sodium channels and PAR2-dependent mechanisms. In keratinocytes, P-CTX-2 also induced voltage-gated sodium channels and PAR2-dependent marked calcium response. In the cocultured cells, P-CTX-2 significantly increased cathepsin S activity, and cathepsin S and PAR2 antagonists almost abolished P-CTX-2‒elicited substance P release. Keratinocytes synergistically favored the induced substance P release. Our results demonstrate that the sensory effects of CTXs involve the cathepsin S-PAR2 pathway and are potentiated by their direct action on nonexcitable keratinocytes through the same pathway.

Advances in Detecting Ciguatoxins in Fish

Ciguatera fish poisoning (CFP) is currently the most common marine biotoxin food poisoning worldwide, associated with human consumption of circumtropical fish and marine invertebrates that are contaminated with ciguatoxins. Ciguatoxins are very potent sodium-channel activator neurotoxins, that pose risks to human health at very low concentrations (>0.01 ng per g of fish flesh in the case of the most potent Pacific ciguatoxin). Symptoms of CFP are nonspecific and intoxication in humans is often misdiagnosed. Presently, there is no medically approved treatment of ciguatera. Therefore, to mitigate the risks of CFP, reliable detection of ciguatoxins prior to consumption of fish tissue is acutely needed, which requires application of highly sensitive and quantitative analytical tests. During the last century a number of methods have been developed to identify and quantify the concentration of ciguatoxins, including in vivo animal assays, cell-based assays, receptor binding assays, antibody-based immunoassays, electrochemical methods, and analytical techniques based on coupling of liquid chromatography with mass spectrometry. Development of these methods, their various advantages and limitations, as well as future challenges are discussed in this review.

Effects of dietary exposure to ciguatoxin P-CTX-1 on the reproductive performance in marine medaka (Oryzias melastigma)

Ciguatoxins are natural compounds produced by benthic dinoflagellates Gambierdiscus and Fukuyoa spp., which cause fish intoxication by ciguatera fish poisoning. This study aimed to assess the dietary exposure effects of ciguatoxin P-CTX-1 on the reproductive performance in marine medaka (Oryzias melastigma). Fish which ingested >1.16 pg·day^-1 for 21 days exhibited abnormal behaviors including diarrhea, abnormal swimming, loss of appetite and decreased egg production. After 7-day exposure to P-CTX-1 at a dose of 1.93 pg·day^-1, significant gender-specific differences in reproductive performance and decreased hatching rate of the offspring were observed. Chemical analysis of P-CTX-1 showed that the P-CTX-1 accumulation rates were 24.1 ± 1.4% in female fish and 9.9 ± 0.4% in male fish, and 0.05 pg·egg^-1 was detected. The results illustrate that dietary exposure to P-CTX-1 affected the reproductive performance and survival of offspring, and caused bioaccumulation and maternal transfer of P-CTX-1 in marine medaka.

A descriptive study of ciguatera fish poisoning in Cook Islands dogs and cats: Exposure history, clinical signs, and formulation of a case definition

BACKGROUND AND AIM

Ciguatera fish poisoning (CFP) is a multisystem toxicosis caused by the ingestion of warm water marine species. Dogs and cats are susceptible to CFP, but there is little published and much unknown about the condition in these species. This study aims to describe the syndrome of CFP in dogs and cats and to develop a case definition.

MATERIALS AND METHODS

Six years (March 2011-February 2017) of medical records from the Esther Honey Foundation Animal Clinic (the only veterinary clinic in the Cook Islands during the study period) were reviewed to identify cases of CFP. Data relating to exposure history and clinical signs were collected.

RESULTS

Two hundred forty-six cases of CFP were identified, comprising 165 dogs and 81 cats. Fish ingestion was documented in 29% of cases. Reef/lagoon fish and moray eels were most commonly implicated. The toxicosis was characterized by motor dysfunction with a high frequency of ataxia and paresis/paralysis/recumbency. Respiratory and gastrointestinal systems were also affected, especially in canine CFP cases. A multi-tiered case definition and a diagnostic algorithm for CFP in dogs and cats were developed based upon the findings of this study and a review of the existing literature.

CONCLUSION

This case series is the largest study of canine and feline CFP to date. It documents the exposure history of cases and describes in detail clinical signs of the toxicosis. It also proposes a system of case classification that has the potential to both assist the diagnosis of CFP and facilitate future surveillance and research activities.

A Curious Case of Ciguatera Fish Poisoning in the Midwest and a Review for Clinicians

BACKGROUND

Ciguatera poisoning is one of the most prevalent types of fish poisoning, but it is often underreported, leading many health practitioners to be unfamiliar in correctly identifying and treating this toxicity.

CASE REPORT

We present a case of ciguatera toxicity encountered in an emergency department in a Midwest community hospital setting. A 56-year-old woman presented to the ED with symptoms of perioral numbness, generalized pruritis, and hot/cold temperature reversal. Through careful history taking it was determined that the patient had recently returned from vacationing in the Caribbean and had been consuming meals containing various types of fish. A clinical diagnosis of ciguatera toxicity was made, and the patient was treated supportively. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This topic is important in the realm of emergency medicine because it presents a known toxicologic pathogen in an unsuspecting geographic location. This case highlights the importance of maintaining broad differentials and considering a patient's travel and exposure history to make the clinical diagnosis of ciguatoxin as well as the importance of preventative management to avoid recurrence of symptoms. We review the etiology of this fascinating toxin as well as the clinical implications in the diagnosis and management of this toxicity.

Ciguatera poisoning in French Polynesia: insights into the novel trends of an ancient disease

Ciguatera is a non-bacterial seafood poisoning highly prevalent in French Polynesia where it constitutes a major health issue and a major threat to food sustainability and food security for local populations. Ciguatera results from the bioaccumulation in marine food webs of toxins known as ciguatoxins, originating from benthic dinoflagellates in the genera Gambierdiscus and Fukuyoa. Ciguatera is characterized by a complex array of gastrointestinal, neurological and cardiovascular symptoms. The effective management of patients is significantly hampered by the occurrence of atypical forms and/or chronic sequelae in some patients, and the lack of both a confirmatory diagnosis test and a specific antidote. In addition, recent findings have outlined the implication of novel species of the causative organisms as well as new vectors, namely marine invertebrates, in ciguatera outbreaks. Another novel trend relates to the geographical expansion of this disease to previously unaffected areas, not only in certain island groups of French Polynesia but also in temperate regions worldwide, as a likely consequence of the effects of climate change.

Taxonomy and toxin production of Gambierdiscus carpenteri (Dinophyceae) in a tropical marine ecosystem: The first record from the Philippines

Morphological and phylogenetic analysis showed that the Gambierdiscus isolate from Bolinao, Philippines belongs to the species of G. carpenteri. It was morphologically more similar to the Merimbula strain than the subtropical Florida Keys strain. Growth and toxin production were also investigated at varying levels of temperature, salinity, and irradiance. Gambierdiscus are known to grow favorably in a low light environment. However, this study showed high growth rates of G. carpenteri even at high irradiance levels. Generally, cells produced more toxins at lower treatment levels. Highest cellular toxin content recorded was 7.48 ± 0.49 pg Pbtx eq/cell at culture conditions of 25 °C, 100 μmol photons m^-2 s^-1, and salinity of 26. Growth rate and toxin production data suggest that cells produced more toxins during the slowest growth at certain range of treatments. This information gives insight into how changes in environmental conditions may affect toxin production and growth of G. carpenteri.

Synergistic Effect of Transient Receptor Potential Antagonist and Amiloride against Maitotoxin Induced Calcium Increase and Cytotoxicity in Human Neuronal Stem Cells

Maitotoxins (MTX) are among the most potent marine toxins identified to date causing cell death trough massive calcium influx. However, the exact mechanism for the MTX-induced calcium entry and cytotoxicity is still unknown. In this work, the effect of MTX-1 on the cytosolic free calcium concentration and cellular viability of human neuronal stem cells was evaluated. MTX elicited a concentration-dependent decrease in cell viability which was already evident after 1 h of treatment with 0.25 nM MTX; however, at a concentration of 0.1 nM, the toxin did not cause cell death even after 14 days of exposure. Moreover, the toxin caused a concentration dependent rise in the cytosolic calcium concentration which was maximal at toxin concentrations of 1 nM and dependent on the presence of extracellular calcium on the bathing solution. Several pharmacological approaches were employed to evaluate the role of canonical transient potential receptor channels (TRPC) on the MTX effects. The results presented here lead to the identification of the TRPC4 channels as contributors to the MTX effects in human neuronal cells. Both, the calcium increase and the cytotoxicity of MTX were either fully (for the calcium increase) or partially (in the case of cytotoxicity) reverted by the blockade of canonical TRPC4 receptors with the selective antagonist ML204. Furthermore, the sodium proton exchanger blocker amiloride also partially inhibited the calcium rise and the cell death elicited by MTX while the combination of amiloride and ML204 fully prevented both the cytotoxicity and the calcium rise elicited by the toxin.

Human Poisoning from Marine Toxins: Unknowns for Optimal Consumer Protection

Marine biotoxins are produced by aquatic microorganisms and accumulate in shellfish or finfish following the food web. These toxins usually reach human consumers by ingestion of contaminated seafood, although other exposure routes like inhalation or contact have also been reported and may cause serious illness. This review shows the current data regarding the symptoms of acute intoxication for several toxin classes, including paralytic toxins, amnesic toxins, ciguatoxins, brevetoxins, tetrodotoxins, diarrheic toxins, azaspiracids and palytoxins. The information available about chronic toxicity and relative potency of different analogs within a toxin class are also reported. The gaps of toxicological knowledge that should be studied to improve human health protection are discussed. In general, gathering of epidemiological data in humans, chronic toxicity studies and exploring relative potency by oral administration are critical to minimize human health risks related to these toxin classes in the near future.

Transcriptomic Analysis of Ciguatoxin-Induced Changes in Gene Expression in Primary Cultures of Mice Cortical Neurons

Ciguatoxins are polyether marine toxins that act as sodium channel activators. These toxins cause ciguatera, one of the most widespread nonbacterial forms of food poisoning, which presents several symptoms in humans including long-term neurological alterations. Earlier work has shown that both acute and chronic exposure of primary cortical neurons to synthetic ciguatoxin CTX3C have profound impacts on neuronal function. Thus, the present work aimed to identify relevant neuronal genes and metabolic pathways that could be altered by ciguatoxin exposure. To study the effect of ciguatoxins in primary neurons in culture, we performed a transcriptomic analysis using whole mouse genome microarrays, for primary cortical neurons exposed during 6, 24, or 72 h in culture to CTX3C. Here, we have shown that the effects of the toxin on gene expression differ with the exposure time. The results presented here have identified several relevant genes and pathways related to the effect of ciguatoxins on neurons and may assist in future research or even treatment of ciguatera. Moreover, we demonstrated that the effects of the toxin on gene expression were exclusively consequential of its action as a voltage-gated sodium channel activator, since all the effects of CTX3C were avoided by preincubation of the neurons with the sodium channel blocker tetrodotoxin.

Toxicological Investigations on the Sea Urchin Tripneustes gratilla (Toxopneustidae, Echinoid) from Anaho Bay (Nuku Hiva, French Polynesia): Evidence for the Presence of Pacific Ciguatoxins

The sea urchin Tripneustes gratilla (Toxopneustidae, Echinoids) is a source of protein for many islanders in the Indo-West Pacific. It was previously reported to occasionally cause ciguatera-like poisoning; however, the exact nature of the causative agent was not confirmed. In April and July 2015, ciguatera poisonings were reported following the consumption of T.gratilla in Anaho Bay (Nuku Hiva Island, Marquesas archipelago, French Polynesia). Patient symptomatology was recorded and sea urchin samples were collected from Anaho Bay in July 2015 and November 2016. Toxicity analysis using the neuroblastoma cell-based assay (CBA-N2a) detected the presence of ciguatoxins (CTXs) in T.gratilla samples. Gambierdiscus species were predominant in the benthic assemblages of Anaho Bay, and G.polynesiensis was highly prevalent in in vitro cultures according to qPCR results. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) analyses revealed that P-CTX-3B was the major ciguatoxin congener in toxic sea urchin samples, followed by 51-OH-P-CTX-3C, P-CTX-3C, P-CTX-4A, and P-CTX-4B. Between July 2015 and November 2016, the toxin content in T.gratilla decreased, but was consistently above the safety limit allowed for human consumption. This study provides evidence of CTX bioaccumulation in T.gratilla as a cause of ciguatera-like poisoning associated with a documented symptomatology.

Tectus niloticus (Tegulidae, Gastropod) as a Novel Vector of Ciguatera Poisoning: Clinical Characterization and Follow-Up of a Mass Poisoning Event in Nuku Hiva Island (French Polynesia)

Ciguatera fish poisoning (CFP) is the most prevalent non-bacterial food-borne form of poisoning in French Polynesia, which results from the consumption of coral reef fish naturally contaminated with ciguatoxins produced by dinoflagellates in the genus Gambierdiscus. Since the early 2000s, this French territory has also witnessed the emergence of atypical forms of ciguatera, known as ciguatera shellfish poisoning (CSP), associated with the consumption of marine invertebrates. In June 2014, nine tourists simultaneously developed a major and persistent poisoning syndrome following the consumption of the gastropod Tectus niloticus collected in Anaho, a secluded bay of Nuku Hiva Island (Marquesas Archipelago, French Polynesia). The unusual nature and severity of this event prompted a multidisciplinary investigation in order to characterize the etiology and document the short/long-term health consequences of this mass-poisoning event. This paper presents the results of clinical investigations based on hospital medical records, medical follow-up conducted six and 20 months post-poisoning, including a case description. This study is the first to describe the medical signature of T. niloticus poisoning in French Polynesia and contributed to alerting local authorities about the potential health hazards associated with the consumption of this gastropod, which is highly prized by local communities in Pacific island countries and territories.

Toxins That Affect Voltage-Gated Sodium Channels

Voltage-gated sodium channels (VGSCs) are critical in generation and conduction of electrical signals in multiple excitable tissues. Natural toxins, produced by animal, plant, and microorganisms, target VGSCs through diverse strategies developed over millions of years of evolutions. Studying of the diverse interaction between VGSC and VGSC-targeting toxins has been contributing to the increasing understanding of molecular structure and function, pharmacology, and drug development potential of VGSCs. This chapter aims to summarize some of the current views on the VGSC-toxin interaction based on the established receptor sites of VGSC for natural toxins.

Ciguatera fish Poisoning: a Challenge to Emergency Physicians

Seven patients from two families presented with ciguatera poisoning after fish consumption. They suffered most of the typical clinical features of ciguatera poisoning and were given supportive treatments. Three of them were given mannitol infusion and showed improvement in symptoms. All of them were discharged within two days.

Mechanisms and Effects Posed by Neurotoxic Products of Cyanobacteria/Microbial Eukaryotes/Dinoflagellates in Algae Blooms: a Review

Environmental toxins produced by cyanobacteria and dinoflagellates have increasingly become a public health concern due to their ability to damage several tissues in humans. In particular, emerging evidence has called attention to the neurodegenerative effects of the cyanobacterial toxin β-N-methylamino-L-alanine (BMAA). Furthermore, other toxins such as anatoxin, saxitoxin, microcystin, nodularin and ciguatoxin also have a different range of effects on human tissues, including hepatotoxicity, neurotoxicity and gastrointestinal irritation. However, the vast majority of known environmental toxins have not yet been examined in the context of neurodegenerative disease. This review aims to investigate whether neurotoxic mechanisms can be demonstrated in all aforementioned toxins, and whether there exists a link to neurodegeneration. Management of toxin exposure and potential neuroprotective compounds is also discussed. Collectively, all aforementioned microbial toxins are likely to exert some form of neuronal damage, with many of their modes of action consistent with neurodegeneration. This is important in advancing our current understanding of the cytotoxic potential of environmental toxins upon human brain function, particularly in the context of age-related neurodegenerative disease.

Ladder-Shaped Ion Channel Ligands: Current State of Knowledge

Ciguatoxins (CTX) and brevetoxins (BTX) are polycyclic ethereal compounds biosynthesized by the worldwide distributed planktonic and epibenthic dinoflagellates of Gambierdiscus and Karenia genera, correspondingly. Ciguatera, evoked by CTXs, is a type of ichthyosarcotoxism, which involves a variety of gastrointestinal and neurological symptoms, while BTXs cause so-called neurotoxic shellfish poisoning. Both types of toxins are reviewed together because of similar mechanisms of their action. These are the only molecules known to activate voltage-sensitive Na⁺-channels in mammals through a specific interaction with site 5 of its α-subunit and may compete for it, which results in an increase in neuronal excitability, neurotransmitter release and impairment of synaptic vesicle recycling. Most marine ciguatoxins potentiate Nav channels, but a considerable number of them, such as gambierol and maitotoxin, have been shown to affect another ion channel. Although the extrinsic function of these toxins is probably associated with the function of a feeding deterrent, it was suggested that their intrinsic function is coupled with the regulation of photosynthesis via light-harvesting complex II and thioredoxin. Antagonistic effects of BTXs and brevenal may provide evidence of their participation as positive and negative regulators of this mechanism.

[First ciguatera outbreak in Germany in 2012]

In November 2012, 23 cases of ciguatera with typical combinations of gastrointestinal and neurological symptoms occurred in Germany after consumption of imported tropical fish (Lutjanus spp.). A questionnaire was used to gather information on the disease course and fish consumption. All patients suffered from pathognomonic cold allodynia. Aside from two severe courses of illness, all other cases showed symptoms of moderate intensity. During a three-year follow-up, seven patients reported prolonged paresthesia for more than one year. Two of them reported further neuropathies over almost three years. This is the first time that long-term persistence of symptoms has been documented in detail. Outbreak cases were allocated to eight clusters in seven German cities. A further cluster was prevented by the successful recall of ciguatoxic fish. Three clusters were confirmed by the detection of ciguatoxin in samples of suspicious and recalled fish. An extrapolation on the basis of ciguatoxic samples revealed twenty prevented cases of ciguatera. Further officially unknown cases should be assumed. During the outbreak investigations, inadvertently falsely labelled fish species and fishing capture areas on import and retail level documents were observed. The ascertainment of cases and the outbreak investigations proved to be difficult due to inconsistent case reports to poisons centers, local health and veterinary authorities. In Germany, many physicians are unaware of the disease pattern of ciguatera and the risks caused by tropical fish. The occurrence of further outbreaks during the following years emphasizes the increasing significance of ciguatera in Germany.

Developmental toxicity and molecular responses of marine medaka (Oryzias melastigma) embryos to ciguatoxin P-CTX-1 exposure

Ciguatoxins are produced by toxic benthic dinoflagellates and cause ciguatera fish poisoning worldwide, but the toxic effects on developing marine fish have not been well investigated. The Pacific ciguatoxin (P-CTX-1), is a potent sodium channel agonist, which is one of the most toxic members among all CTXs. This study evaluated the toxic effects of microinjecting purified Pacific ciguatoxin-1 (P-CTX-1) on embryonic development of marine medaka Oryzias melastigma. A lower 96h-LD₅₀ value was estimated for eleuthero-embryos (1.32ngg^-1) than that for embryos (1.71ngg^-1), indicating that P-CTX-1 is more lethal to newly hatched medaka larvae. P-CTX-1 induced detrimental effects during embryonic development, including hatching failure, abnormalities in physical development (caudal fin malformation and spinal deformities), internal damage (green coloration of the gall bladder and hemorrhaging), immune dysfunction, and altered muscle physiology (bradycardia and hyperkinetic twitching). The results of a transcriptional expression analysis of genes related to the stress/immune responses, cardiac and bone development, and apoptosis supported the observed developmental abnormalities. This study advanced the understanding of P-CTX-1 mediated toxic mechanisms in the development of early life stages of a fish, and thus contributed to the toxicity assessment of CTXs in marine ecosystems.

An Updated Review of Ciguatera Fish Poisoning: Clinical, Epidemiological, Environmental, and Public Health Management

Ciguatera Fish Poisoning (CFP) is the most frequently reported seafood-toxin illness in the world. It causes substantial human health, social, and economic impacts. The illness produces a complex array of gastrointestinal, neurological and neuropsychological, and cardiovascular symptoms, which may last days, weeks, or months. This paper is a general review of CFP including the human health effects of exposure to ciguatoxins (CTXs), diagnosis, human pathophysiology of CFP, treatment, detection of CTXs in fish, epidemiology of the illness, global dimensions, prevention, future directions, and recommendations for clinicians and patients. It updates and expands upon the previous review of CFP published by Friedman et al. (2008) and addresses new insights and relevant emerging global themes such as climate and environmental change, international market issues, and socioeconomic impacts of CFP. It also provides a proposed universal case definition for CFP designed to account for the variability in symptom presentation across different geographic regions. Information that is important but unchanged since the previous review has been reiterated. This article is intended for a broad audience, including resource and fishery managers, commercial and recreational fishers, public health officials, medical professionals, and other interested parties.

Chronic ciguatoxin poisoning causes emotional and cognitive dysfunctions in rats

Ciguatoxins are marine biotoxins that induce the human poisoning syndrome known as ciguatera fish poisoning (CFP). In humans, different kinds of neurological symptoms have been reported after CFP, including anxiety, depression and memory loss. Repetitive exposures to sub-threshold levels of ciguatera toxins may cause irreversible sub-clinical damage, and eventually cause more severe illness. Our previous study has shown that an acute single dose of Pacific ciguatoxin-1 (P-CTX-1) induced synaptic facilitation and blockage of the induction of electrical stimulation-induced long-term potentiation in the medial thalamus-anterior cingulate cortex pathway. Reactive astrogliosis was detected in acute ciguatera poisoning. Despite the reports of complex and prolonged neurological symptoms in patients, few studies have been conducted in animal models to investigate the emotional and cognitive deficits after chronic exposure to ciguatoxin. In the present study, using a rat model with repeated exposures to low dosage of P-CTX-1, we observed development of anxiety-like behavior by open field test and elevated plus maze test, and learning and memory deficits by the Morris water maze; further, decision-making impairment was determined in the chronic P-CTX-1-treated rats by the rats gambling task. We conclude that chronic ciguatera poisoning leads to anxiety, and to impairment of spatial reference memory and decision-making behavior.

Acute Exposure to Pacific Ciguatoxin Reduces Electroencephalogram Activity and Disrupts Neurotransmitter Metabolic Pathways in Motor Cortex

Ciguatera fish poisoning (CFP) is a common human food poisoning caused by consumption of ciguatoxin (CTX)-contaminated fish affecting over 50,000 people worldwide each year. CTXs are classified depending on their origin from the Pacific (P-CTXs), Indian Ocean (I-CTXs), and Caribbean (C-CTXs). P-CTX-1 is the most toxic CTX known and the major source of CFP causing an array of neurological symptoms. Neurological symptoms in some CFP patients last for several months or years; however, the underlying electrophysiological properties of acute exposure to CTXs remain unknown. Here, we used CTX purified from ciguatera fish sourced in the Pacific Ocean (P-CTX-1). Delta and theta electroencephalography (EEG) activity was reduced remarkably in 2 h and returned to normal in 6 h after a single exposure. However, second exposure to P-CTX-1 induced not only a further reduction in EEG activities but also a 2-week delay in returning to baseline EEG values. Ciguatoxicity was detected in the brain hours after the first and second exposure by mouse neuroblastoma assay. The spontaneous firing rate of single motor cortex neuron was reduced significantly measured by single-unit recording with high spatial resolution. Expression profile study of neurotransmitters using targeted profiling approach based on liquid chromatography-tandem mass spectrometry revealed an imbalance between excitatory and inhibitory neurotransmitters in the motor cortex. Our study provides a possible link between the brain oscillations and neurotransmitter release after acute exposure to P-CTX-1. Identification of EEG signatures and major metabolic pathways affected by P-CTX-1 provides new insight into potential biomarker development and therapeutic interventions.

Harmful Algal Blooms and Public Health

The five most commonly recognized Harmful Algal Bloom related illnesses include Ciguatera poisoning, Paralytic Shellfish poisoning, Neurotoxin Shellfish poisoning, Diarrheic Shellfish Poisoning and Amnesic Shellfish poisoning. Although they are each the product of different toxins, toxin assemblages or HAB precursors these clinical syndromes have much in common. Exposure occurs through the consumption of fish or shellfish; routine clinical tests are not available for diagnosis; there is no known antidote for exposure; and the risk of these illnesses can negatively impact local fishing and tourism industries. Thus, illness prevention is of paramount importance to minimize human and public health risks. To accomplish this, close communication and collaboration is needed among HAB scientists, public health researchers and local, state and tribal health departments at academic, community outreach, and policy levels.

Ciguatoxin reduces regenerative capacity of axotomized peripheral neurons and delays functional recovery in pre-exposed mice after peripheral nerve injury

Ciguatera fish poisoning (CFP) results from consumption of tropical reef fish containing ciguatoxins (CTXs). Pacific (P)-CTX-1 is among the most potent known CTXs and the predominant source of CFP in the endemic region responsible for the majority of neurological symptoms in patients. Chronic and persistent neurological symptoms occur in some CFP patients, which often result in incomplete functional recovery for years. However, the direct effects of exposure to CTXs remain largely unknown. In present study, we exposed mice to CTX purified from ciguatera fish sourced from the Pacific region. P-CTX-1 was detected in peripheral nerves within hours and persisted for two months after exposure. P-CTX-1 inhibited axonal regrowth from axotomized peripheral neurons in culture. P-CTX-1 exposure reduced motor function in mice within the first two weeks of exposure before returning to baseline levels. These pre-exposed animals exhibited delayed sensory and motor functional recovery, and irreversible motor deficits after peripheral nerve injury in which formation of functional synapses was impaired. These findings are consistent with reduced muscle function, as assessed by electromyography recordings. Our study provides strong evidence that the persistence of P-CTX-1 in peripheral nerves reduces the intrinsic growth capacity of peripheral neurons, resulting in delayed functional recovery after injury.